The Ivy Apartments, Chicago

Senior Living at the Imperial

The Ivy Apartments

2437 North Southport – Chicago, Illinois – 60614

Telephone: (773) 472-8400 – Fax: (773) 248-3651

Home
Our Community
Our Apartments
- Features
- Floor Plans
Services
Activities
Admissions
Learn More
Contact Us
- Contact Us
- Driving Directions

Change Font Size:^AA +
A_A -

Residency Application

Come see for yourself what makes The Ivy Apartments such a great place to live. Contact our Marketing Director to take a tour and get more information about our community, its services and amenities. Call us at: 773.472.8400

Applying is quick and easy.

You can begin by either filling out the user-friendly Preliminary Application provided or printing the Adobe Reader version below and faxing it back. If you have any questions, our Marketing Director would be more than happy to help.

Residency Application (PDF)

General Information

* indicates required field
Your Name*
Phone*
Address*
City*
State *
Zip
Sex:
Male Female
Email Address*
Date of Birth*
Marital Status *
Emergency Contact / Relationship*
Contact Phone*

Insurance

Medicare
Medicaid
Private
Have you ever resided in one or more of the following (please indicate where)?
Nursing Home
Assisted/Independent Living
Reason for leaving facility

Medical Information

Physician Name*
Phone*
Fax
Address*
City*
State *
Zip
Any Known Allergies?
Do you currently use the services of a caregiver?
Yes No
If Yes, Please Explain

Current Health Status / Diagnosis

Primary*
Secondary
Tertiary
Any diagnosis of a mental illness
Yes No
If Yes, please explain
Date(s) of recent hospitalizations
Reason(s)
List all prescribed and over-the-counter medications
Please indicate if you will need assistance with any of the following Activities Of Daily Living:
Medication Management (oversight, ordering, reminders)
Bathing
Dressing
Grooming
Toileting
Transferring
Escort Service
Incontinence
Housekeeping
Laundry
Other Services

Financial Information

Please indicate your monthly income of the following
Social Security
Pension
Annuity
Other
Please indicate the source of all assets
Please list the total cash value of ALL assets in your name *
I certify that the information listed on this Preliminary Application for residency is true to the best of my knowledge. I understand that providing false information may be grounds for denial of my application.
Check this box to receive a copy of this form

cforms contact form by delicious:days

WordPress | Sandbox

Owned and operated by Claridge Imperial, LTD., an Illinois Corporation

The Ivy Apartments

– 2437 North Southport – Chicago, Illinois – 60614

(877) IVY-APTS

Chicago Web Design | Copyright © 2010 | Website designed by: Blueprintds.com